Symptom and treatment questionnaire

This short questionnaire covers important information your health care provider will want to know about your nasal allergy symptoms and history. To help you prepare for the visit with the health care provider, answer the questions as best you can by checking the appropriate check boxes and typing answers in the empty text boxes. Then click on the Printable Version button to print out the completed form that you can bring to your health care provider's office, along with any other notes or questions to ask your health care provider.

Please note: This checklist is for your personal use only. No personal information you enter is collected by this Web site.

Important Safety Information (continued)

NASONEX may cause slow wound healing. Do not use NASONEX until your nose is healed if you have a sore in your nose, if you have surgery on your nose or if your nose has been injured.

Some people may have eye problems, including glaucoma and cataracts. You should have regular eye exams.

NASONEX may cause immune system problems that can increase your risk of getting infections. Avoid contact with people who have infections like chickenpox or measles while using NASONEX. Tell your doctor about any signs of infection, such as fever, pain, aches, chills, feeling tired, nausea, and vomiting while using NASONEX.

A condition in which the adrenal glands do not make enough steroid hormones may occur. Symptoms can include tiredness, weakness, nausea, vomiting, and low blood pressure.

The most common side effects include headache, viral infection, sore throat, nosebleeds, and coughing.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.